Assessment and referral of complications of mesh surgery for urinary incontinence or pelvic organ prolapse

For women who report new-onset symptoms after having mesh surgery for urine incotinence or pelvic organ prolapse, evaluate whether the symptoms might be caused by a mesh-related complication

• these symptoms could include:
  • pain or sensory change in the back, abdomen, vagina, pelvis, leg, groin or perineum that is:
    • either unprovoked, or
    • provoked by movement or sexual activity and
      
      
    • either generalised, or in the distribution of a specific nerve, such as the obturator nerve
      
      
  • vaginal problems including:
    • discharge, bleeding,
    • painful sexual intercourse, or
    • penile trauma or pain in sexual partners
      
      
  • urinary problems including:
    • recurrent infection,
    • incontinence,
    • retention, or
    • difficulty or pain during voiding
      
      
  • bowel problems including:
    • difficulty or pain on defaecation,
    • faecal incontinence,
    • rectal bleeding or passage of mucus
      
      
  • symptoms of infection, either alone or in combination with any of the symptoms outlined above

Refer women with a suspected mesh-related complication to a urogynaecologist, urologist or colorectal surgeon for specialist assessment.

For women who are referred for specialist evaluation of a suspected mesh complication:

• take a history of all past surgical procedures for prolapse or incontinence using mesh, including the dates, type of mesh and site of mesh placement and the relationship of the symptoms to the surgical procedure(s)
  
  
• consider using a validated pelvic floor symptom questionnaire and a pain questionnaire to aid assessment and decision making
  
  
• perform a vaginal examination to:
  • assess whether mesh is palpable, exposed or extruded
  • localise pain and its anatomical relationship to mesh
    
    
• consider performing a rectal examination, if indicated, to assess for the presence of mesh perforation or fistula
  
  
• consider performing a neurological assessment to assess the distribution of pain, if present, sensory alteration or muscle weakness

For women with a confirmed mesh-related complication or unexplained symptoms after a mesh procedure:

• refer to a consultant at a regional centre specialising in the diagnosis and management of mesh-related complications or
• if the woman has a vaginal exposure of mesh that is smaller than 1 cm2 and no other symptoms, follow the recommendations on vaginal complications
• consider non-surgical treatment with topical oestrogen cream with women who have a single area of vaginal mesh exposure that is smaller than 1 cm2

Reference:

• NICE (April 2019). Urinary incontinence and pelvic organ prolapse in women: management